The University of Pittsburgh Medical Center (UPMC) Health Plan, a health maintenance organization affiliated with the university's School of Medicine, has adopted landmark guidelines for the management of chronic low back pain. As of Jan. 1, 2012, candidates for spine surgery must receive "prior authorization to determine medical necessity," which includes verification that the patient has "tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication." Surgery candidates also must be graduates of the plan's LBP health coaching program. The program features a Web-based decision-making tool designed to help plan members "understand the pros and cons of surgery and high-tech radiology." It is the first reported implementation of such a policy by a health care plan.
Putting a Clamp on the Soaring Rates of Spine Surgery
According to the December 2011 issue of the UPMC Health Plan Physician Partner Update, which informed participating providers of the new guidelines and the rationale for their implementation, "We feel strongly that this clinical initiative will improve the quality of care for members who are considering low back surgery, and that it will facilitate their involvement in the decision-making process." The update also noted, "Surgical procedures for low back surgery performed without prior authorization will not be reimbursed at either the specialist or the hospital level."
| AConservative Strategy for Managing Chronic LBP • PCPdiscussion related to self-care consisting of rest, ice, compression andelevation (RICE) • Screeningfor psychosocial factors or "yellow flags" and incorporate behavioralinterventions as appropriate with other treatment interventions • Educationon self-management techniques – functional ability assessment and educationon return to work / usual activity and function • Enrollmentand graduation from UPMC Health Plan Health Coach's Low Back Pain Program(mandatory) which may also include participation in other programs such asweight loss, physical activity, tobacco cessation, depression and/or stress • Earlyreferral to chiropractor or physical therapist, but before advanced imaging,for manipulation/mobilization; stabilization exercises; directionalpreference strategies – member and/or provider movements that abolish orcause centralization of pain (McKenzie self-treatment repeated movements thatcentralize pain) • Detaileddocumentation of extent and response to conservative treatment includingchiropractor/physical therapy documentation SOURCE: UPMC Health PlanPolicy and Procedure Manual, October2011: Surgical Management of Low Back Pain (partial list of considerations prior to spine surgery to determine medicalnecessity). Complete policy available at www.upmchealthplan.com/pdf/PandP/MP.043.pdf. |
"The UPMC should be congratulated for its leadership is establishing policies to assure that the least invasive and most likely to be successful care strategies, including chiropractic care, are applied for a meaningful period of time before surgical considerations are made. This decision is both an important recognition of the value of chiropractic care in the acute low back pain environment as well as a recognition of the clinical and economic downsides to spinal surgery in this situation."
Headquartered in Pittsburgh, the UPMC Health Plan covers insureds in 15 counties in western Pennsylvania. The plan integrates 20 hospitals, 400 doctors' offices and outpatient sites.
Chiropractic Services: What the UPMC Health Plan Covers
"It is the policy of UPMC Health Plan to recognize chiropractic services and adjunctive procedures as appropriate and consistent with good medical practice and will provide coverage when the services are medically necessary and covered by the member's benefit plan for the specific indications detailed in this policy. Coverage is limited to medically necessary services provided by a licensed doctor of chiropractic, within the scope of his/her license."
"Covered chiropractic services include evaluation and management, manipulation, spinal X-rays, therapeutic exercise, and adjunctive procedures that are appropriate and medically necessary for neuromusculoskeletal conditions. ... Indications for Chiropractic Services: Indicated for primary, neuro-musculoskeletal symptoms involving the spine, para-spinal soft tissues, and extremities. Indications for Manipulation: Manipulation is appropriate to restore function that has been reduced or lost by illness or injury. Indications for Adjunctive Procedures: Adjunctive procedures are appropriate to restore function and prevent disability following injury. Indications for Therapeutic Exercise: Indicated for improvement or to restore functional status by building strength, endurance and flexibility of the affected region."
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
